Inspection on 16/01/06 for Ayeesha-Raj

This inspection was carried out on 16th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ayeesha-Raj 03/09/09

Ayeesha-Raj 30/08/07

Ayeesha-Raj 20/04/06

Ayeesha-Raj 02/06/05

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Ayeesha-Raj 89 Loughborough Road Mountsorrel Leicestershire LE12 7AU Lead Inspector Joanne Vyas Unannounced Inspection 16th January 2006 10:00 Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ayeesha-Raj Address 89 Loughborough Road Mountsorrel Leicestershire LE12 7AU 01509 413667 01509 413667 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Cherre Residential Care Ltd Vacant Care Home 20 Category(ies) of Learning disability (20) registration, with number of places Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 2nd June 2005 Brief Description of the Service: Ayeesha Rajj is registered to provide care for twenty adults with learning disabilities. Formally known as David Leslie it was bought by Cherre Residential Care Ltd. in April 2005. This company also owns a further two homes in the Leicester area. The home is situated on the main road running through Mountsorrel. It is located close to the centre of the village and has good access to public transport services into Leicester and Loughborough. The original house, a large detached property, has been extended to provide three shared and fourteen single bedrooms. It has three lounge areas, all of which are located on the ground floor. The garage has been converted into a games area for service users. There is off road parking for staff and visitors. Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the CSCI is upon outcomes for service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involved selecting four people who live in the home and tracking the care they received through looking at their records, discussion with them and care staff and observation of care practices. This unannounced inspection took place between 10:00am and 2:30pm on a weekday and was carried out by one inspector as part of the annual plan of inspection. What the service does well: What has improved since the last inspection? What they could do better: There were two issues of serious concern highlighted at this inspection. These were that people who live in the home have access to the boiler and medication was not given as per prescription. Other issues included people who live in the home paying for staff costs when staff accompany them on outings, meals out etc.; some parts of the home were cold due to the boiler not working properly and a lounge was heated by a potable radiator, which was extremely hot to the touch; and the floor covering in two areas had not been fitted properly causing a trip hazard. The home were addressing the issue of the boiler not working properly at the time of the inspection. The home does not yet have a Registered Manager. Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion but were assessed at the previous inspection carried out on the 2nd June 2005. EVIDENCE: Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 The individual needs and choices of service users are fully addressed. EVIDENCE: • • Risk assessments are carried out for all people who live in this home. Care planning is comprehensive and regularly reviewed. People living in the home said they felt their needs and choices are addressed. Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15, 16, 17 Staff attitudes support choice and independence for people living in this home in their daily living activities. EVIDENCE: • Staff relationships with people living in this home have much improved from the previous inspection. Staff were observed interacting positively with people living in the home, using signing (Makaton) where appropriate. The afternoon of the inspection was planned as a training session for staff to learn more Makaton as appropriate to a specific person living in the home. People living in this home spoke about contact they have with their families and friends. A telephone is available for people to use in one of the lounges. Staff were observed offering choices of meals to people living in the home at lunchtime. Two choices were offered but staff made alternatives if anyone didn’t want what was offered. One person needed support with their meal and a member of staff gave this sensitively and with dignity. People living in this home said they enjoyed the meals that are on offer. • • Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 20 Generally, the healthcare needs of people living in this home are identified and met. However, there were serious concerns with regard to the administration of medication, which may put people living in this home at risk. EVIDENCE: • • All people living in this home receive appropriate healthcare. Medication is stored, handled and disposed of appropriately. However, upon sampling the medication records of one person living in the home, it was found that medication had not been given as per their prescription. Also a number of recording sheets were hand written for “as required” and short-term medication such as anti-biotics. The hand written entries were not always comprehensive, for example, they did not state the dose required or how many times in 24 hours a drug could be taken etc. Medication training has not yet been given to staff but is planned for the near future. • Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The inspector was satisfied that the home responds to complaints and concerns effectively. However, the inspector felt people living in this home were not protected from financial abuse. EVIDENCE: • • • People living in this home are given opportunities to make complaints and know how to do this. Complaints are responded to appropriately. All staff have received training on adult protection procedures and are reminded regularly throughout staff meetings and one to one supervision sessions. The records of finances for people living in the home were robust. However, people living in this home are paying for staff costs when staff take them out, for example, for a meal, entrance fees etc. This is not fully reflected in their terms and conditions document and the inspector was not convinced that all people living in this home would understand the financial implications for them. Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Ayeesha Rajj is homely, clean and comfortable but people living in this home remain at risk from some health and safety issues. EVIDENCE: • • The home is spacious, clean and furnished to a high standard. At the time of the inspection, the home was struggling with the heating as the boiler was cutting out. A plumber had been asked to visit the home and was due that afternoon. Some areas of the home were cold. A portable radiator heated the large lounge, which was very hot to touch. The inspector was concerned that some people living in the home are unstable on their feet and may fall onto the heater. The boiler is housed in the laundry room, which is not locked therefore giving people living in the home full access to the boiler. The Head of Service explained that people living in the home are encouraged to do their washing as part of their daily living skills. However the inspector was seriously concerned about the accessibility of the boiler. The floor covering in the downstairs bathroom and a single toilet upstairs had been poorly fitted and should be refitted to prevent people living in the home tripping. • • Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 The deployment and number of staff is sufficient to meet the needs of the people living in this home. Staff are well trained and supported ensuring service users receive a good quality service. Recruitment processes protect and support service users. EVIDENCE: • • There are three staff on duty each morning and evening and one waking and one sleeping night staff. Staff receive an eight-week induction and are asked to complete the Learning Disability Award Framework if they have little or no experience of people with learning disabilities. One member of staff has completed the National Vocational Qualification level three and another member of staff is completing it. Two staff have got their National Vocational Qualification level two. All staff receive one to one supervision sessions every eight weeks and an annual appraisal. Staff meetings are held every two months. Recruitment processes are robust. • • Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 42 The staff team benefits from good management, leadership and direction from the Head of Service, which ensures people living in this home receive consistent, quality care. People living in this home remain at risk from some health and safety issues. EVIDENCE: • The Registered Manager post remains vacant although the Registered Provider has handed over the management of the home to the Head of Service who intends to apply for the post. Although the home appears to be running well generally, a score of 1 can only be given, as there is no Registered Manager in post. See standard 24 with regard to health and safety issues within this home. The home has a current fire risk assessment and other environmental risk assessments such as COSHH. All fire checks and other health and safety checks are carried out appropriately. • • Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 1 X 1 X X X X 1 X Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13 Requirement The Registered Person must ensure that all medication is given as per the doctor’s instruction. The Registered Person must ensure that all service users are protected from abuse. The Registered Person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. The Registered Person shall ensure that the premises to be used as a care home are kept in a good state of repair. The Registered Person must put forward to the Commission for Social Care Inspection, a suitably qualified and experienced person to register as manager. (This requirement was made previously at the last inspection). Timescale for action 16/01/06 2 3 YA23 YA42YA24 13 12 30/01/06 16/01/06 4 YA24 23 30/01/06 5 YA37 8 30/06/06 Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA20 YA23 Good Practice Recommendations The Registered Person is recommended to have all prescriptions typed by the dispensing pharmacist onto the record of administration. The Registered Person is recommended to update the terms and conditions document to fully reflect what the service asks the service users to pay for in addition to their rent and to seek written agreement from service users and their placing officers for service users to cover staff costs when staff accompany them for trips out. Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ayeesha-Raj DS0000063000.V279209.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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